What is Posttraumatic Headache (Headache After Injury)?
Post-traumatic headaches (PTHA) often follow a traumatic brain injury (TBI) and can evolve into long-term, possibly disabling conditions. These types of headaches can be grouped into two main categories. Acute PTHA refers to headaches after a TBI that clear up within three months, while persistent PTHA describes headaches that persist beyond this period. It’s also important to note that there are several possible variations of PTHA.
What Causes Posttraumatic Headache (Headache After Injury)?
The latest International Classification of Headache Disorders (ICHD-3) states that post-traumatic headaches are headaches that start within seven days of a trauma, injury, regaining consciousness, or the ability to feel and report pain. However, this definition has been questioned in recent times because some patients can experience headaches several months to a year after their injury or trauma. The ICHD-3 doesn’t provide the specific types of diagnoses that could guide doctors on how to treat and manage different forms of post-traumatic headaches.
For people in the military, post-traumatic headaches are a significant issue. Because the physical and mental impact of combat-related injury is much greater than civilian injuries, resulting brain injuries and their effects need to be discussed separately. Also, there is a significant overlap between post-traumatic headaches and post-traumatic stress disorder (PTSD). The most common cause of injury for U.S. military personnel is combat-related explosions.
Risk Factors and Frequency for Posttraumatic Headache (Headache After Injury)
Headache is a common issue after experiencing a traumatic brain injury (TBI), with 30% to 90% of TBI patients reporting this symptom. A year after the trauma, 18% to 22% of these patients still have headaches. This wide range is because most TBI cases are mild, often known as concussions, and these patients might not immediately go to a doctor.
Post-traumatic headaches seem to be more common in patients who have had mild TBIs than those who have had severe ones. However, those with moderate to severe TBIs are more likely to report long-lasting headaches. It also appears that twice as many female patients have these headaches compared to male patients. Furthermore, if a person has a previous history of headaches, they are more likely to report post-traumatic headaches, with 45% of patients stating this.
According to a classification of headache subtypes, those that mimic migraines and tension-type headaches are reported most frequently. An Australian study found that mild TBI patients are seven times more likely to report headaches after an injury compared to other trauma patients without a brain injury.
Signs and Symptoms of Posttraumatic Headache (Headache After Injury)
After a traumatic brain injury (TBI), regardless of whether it’s mild or more severe, it’s crucial for doctors to check patients for headaches. The International Classification of Headache Disorders-3 (ICHD-3) states that post-traumatic headaches should appear within 7 days of the injury. If a patient’s post-traumatic headache lasts for more than 3 months, it’s classified as a persistent post-traumatic headache. These headaches don’t have a specific type or ‘phenotype’, and people with TBI often describe symptoms that are similar to various other types of headaches.
Military personnel who have been in combat might also report additional symptoms. Post-traumatic headaches are part of a group of symptoms referred to as post-concussive syndrome (PCS). PCS includes:
- Dizziness
- Fatigue
- Irritability
- Anxiety
- Insomnia
- Decreased cognition
It’s worth noting that in populations with a higher prevalence of Posttraumatic Stress Disorder (PTSD), such as veterans, diagnosing post-traumatic headaches and PCS can be more complex. During a patient’s appointment, doctors should ask about the severity of the patient’s headache and any associated symptoms. They should also check the patient’s neck movement range, physically examine the head and neck, and assess the patient’s neurologic status.
Testing for Posttraumatic Headache (Headache After Injury)
Post-traumatic headaches, like many other common types of headaches, are diagnosed through a patient’s symptoms, not through medical tests or imaging. Usually, routine scans or lab tests aren’t needed and don’t typically add much information for the doctors. Even after a traumatic brain injury (TBI), which often leads to post-traumatic headaches, brain imaging doesn’t usually show any noticeable structural changes.
If you’ve been diagnosed with a post-traumatic headache after a TBI, you typically won’t need any further imaging if you’ve already had a thorough evaluation for the TBI. However, if you’ve had a TBI and start getting new headache symptoms, additional checking might be needed to rule out other possible causes of the headaches.
In some cases, a head CT scan (which doesn’t use contrast dye) might be done to make sure there’s no bleeding in the brain, which can be a particular concern for older people. A brain MRI might also be done to rule out problems like a stroke or tumors. If there’s a sudden change in your headaches or your neurological status – like your ability to think, move, or sense things – then additional imaging might be needed to find out if something else might be causing your headaches.
Treatment Options for Posttraumatic Headache (Headache After Injury)
Post-traumatic headaches (PTHS) can be managed in several ways, such as taking medicines, doing physical therapy, and undergoing psychological therapy. Some ways to help without using drugs include cognitive-behavioral therapy, which involves changing harmful thought processes, biofeedback, a process of gaining control over your body’s functions, and physical therapy. Studies recommend a team-based treatment approach as the most effective.
Drug therapy should be customized to the specific type of PTHA, if known. This can include medicine for immediate relief as well as preventative treatment. Immediate relief can be provided through pain relievers called non-steroidal anti-inflammatories (NSAIDs), triptans, and IV anti-nausea medicine. Preventative treatments can include antidepressants, seizure drugs, and a medicine called gabapentin.
Interventional procedures, such as nerve-blocking injections, have also been tried for PTHA, but more research is needed. These treatments have shown some benefit in reducing the severity and frequency of headaches.
Treatment for post-traumatic headaches can depend on the specific type of headache:
For tension-type headaches, pain relievers like NSAIDs are recommended for quick relief. For preventative treatment, antidepressants have been effective. In severe cases, a medication called butalbital may be beneficial.
For headaches related to jaw tension, intraoral devices may provide relief. In severe cases, botulinum toxin injections into the jaw joint may be useful.
For migraines, herbs, vitamins, and minerals may help prevent attacks. Quick relief can be provided by triptans – they are the primary treatment for needle migraines. Pain relievers, nausea medications, and a group of medicines called ergot derivatives are also used. Opioids, though, are not recommended.
In the case of neuralgias and neuromas, oral medicines and botulinum toxin injections may not be effective. Steroid injections and radiofrequency ablation, a procedure that involves destroying nerve tissue, can be beneficial. Surgery could be an option as well for neuromas.
Cervicogenic headaches, those caused by issues in the neck, may not be relieved by oral medications. Physical therapy and manual manipulation of the neck have proven beneficial. Interventional procedures, like nerve blocks and radiofrequency ablation, may show promise. However, botulinum toxin injections might not be effective for this type of headache.
What else can Posttraumatic Headache (Headache After Injury) be?
When trying to diagnose headaches that occur after an injury, doctors categorize potential causes into two groups: non-emergency and emergency conditions.
Non-Emergency Conditions Include:
- Regular tension headaches
- Migraine headaches
- Pain caused by damaged or irritated nerves (neuralgias/neuromas)
- Headaches stemming from the neck (cervicogenic headaches)
- Overusing medication
- Pain in the jaw and surrounding areas (craniomandibular headaches)
Emergency Conditions Include:
- A stroke, either due to lack of blood supply (ischemic) or bleeding in the brain (hemorrhagic)
- An aneurysm, which is a weakened area in a blood vessel that can rupture
- A tear in a neck artery (cervical artery dissection)
- Water on the brain (hydrocephalus)
- A brain tumor (cerebral neoplasm)
- Inflammation in a temporal artery, which supplies blood to the brain (temporal arteritis)
What to expect with Posttraumatic Headache (Headache After Injury)
A study by Hoffman and his team found that 71% of patients experienced headaches in the first year after a moderate or severe traumatic brain injury (TBI). At their first check-up, 46% of patients reported headaches, and 44% had new or ongoing headaches a year later. Another similar study found slightly higher rates, with 91% of patients experiencing headaches after a mild traumatic brain injury (mTBI). In this study, 54% had headaches at their first examination and 58% reported headaches one year after the injury.
Possible Complications When Diagnosed with Posttraumatic Headache (Headache After Injury)
Headaches after a traumatic brain injury can significantly impact a person’s ability to return to their normal activities. In fact, about 35% of people with these post-traumatic headaches don’t return to work even after three months. Because these headaches can become chronic, there’s also a higher risk of becoming dependent on pain medications like opioids.
Recovery from Posttraumatic Headache (Headache After Injury)
There aren’t any official recovery guidelines for headaches that occur after trauma. However, for headaches originating from neck issues, physical therapy is recommended.
Preventing Posttraumatic Headache (Headache After Injury)
People who have had a traumatic brain injury need to know that they might experience headaches afterwards. These headaches can be very intense and might last for a very long time, but there are ways to treat them. The treatments can range from changes in behavior, to medication, to medical procedures. Doctors should comfort their patients by letting them know that these headaches, while uncomfortable, aren’t going to be fatal. There’s no exact way these headaches will show up, and they can take on features similar to other types of headaches. Both the patient and their healthcare team should be aware of this.